NORTHWEST CLINICAL GENOMICS LABORATORY ... Northwest Clinical Genomics Laboratory Box 357655 1959 NE

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  • UW LABORATORY FOR PRECISION DIAGNOSTICS NORTHWEST CLINICAL GENOMICS LABORATORY

    1959 NE PACIFIC AVE., LAB H-561, SEATTLE, WA 98195 PHONE: 206-543-0459; FAX: 206-616-1899 www.uwcpdx.org

    Name: Name:

    Address: Organization:

    City: State: ZIP: Address:

    Phone: City: State: ZIP:

    Patient ID (MRN): Phone: FAX: Date of birth: Email:

    Gender: Male Female Unknown

    Ethnic background (select all that apply): Name:

    Hispanic Address:

    Asian City: State: ZIP:

    Native American Phone: FAX:

    African American ite) Caucasian (White) Ashkenazi Jewish Other: Email:

    Date of collection:

    Date of birth: Patient ID (MRN):

    Clinical (Affected/Unaffected):

    Date of birth: Patient ID (MRN):

    DNA

    Specimen type: Whole blood (EDTA tube) Extracted DNA Other:

    FAMILIAL SAMPLES Mother: Father:

    Saliva Date of birth:

    PATIENT INFORMATION ORDERING PHYSICIAN

    OTHER REPORT RECIPIENT

    SAMPLE INFORMATION Collected by:

    Relative: Relative: Patient ID (MRN): Date of birth:

    TEST TO BE PERFORMED

    Page 1 of 3

    EXOME AND GENOME TEST REQUISITION

    Exome Trio Sequencing and Interpretation (Proband, Mother, Father)

    Exome Duo Sequencing and Interpretation

    Exome Singleton Sequencing and Interpretation (Proband only)

    Exome Comparator Sequencing and Interpretation (Additional family member for support of proband testing)

    Relative's relationship to Proband: Proband Name:

    Reflex Exome Sequencing - (only after completion of exome "panel")

    RAPID option for Exome Sequencing and Interpretation (10 day TAT; additional charges apply)

    Saliva

    Sample type: Blood

    Relationship:

    Patient ID (MRN):

    Genome Trio Sequencing and Interpretation

    Genome Duo Sequencing and Interpretation

    Genome Singleton Sequencing and Interpretation (Proband only)

    Genome Comparator Sequencing and Interpretation (Additional family member for support of proband testing)

    Relative's relationship to Proband: Proband Name:

    Other: DNASalivaSample type: Blood Other:

    DNASalivaSample type: Blood Other: DNASalivaSample type: Blood Other:

    Clinical (Affected/Unaffected):

    Clinical (Affected/Unaffected): Clinical (Affected/Unaffected):

    Relationship:

  • Indication for Study and Pertinent Clinical Information (provide any suspected clinical diagnoses or state if unaffected):

    Previous Genetic Testing: No Yes - Provide results: ______________________________________________________

    Suspected Mode of Inheritance: Dominant Recessive X-linked De novo Mitochondrial

    Medical History: For any section marked "Abnormal" please provide additional information ICD-9 Code(s): ______________

    Perinatal / Prenatal History: Skeletal: Abnormal Normal Unknown Abnormal Normal Unknown

    In Utero Abnormalities of Proband: Muscle, Soft Tissue: Abnormal Normal Unknown Abnormal Normal Unknown

    Growth and Build: Neurologic: Abnormal Normal Unknown Abnormal Normal Unknown

    Head and Neck: Skin, Nails, Hair: Abnormal Normal Unknown Abnormal Normal Unknown

    Voice: Immunology: Abnormal Normal Unknown Abnormal Normal Unknown

    Chest and Thorax: Endocrine System: Abnormal Normal Unknown Abnormal Normal Unknown

    Cardiovascular: Hematology: Abnormal Normal Unknown Abnormal Normal Unknown

    Respiratory: Metabolic: Abnormal Normal Unknown Abnormal Normal Unknown

    Abdomen: Neoplasia: Abnormal Normal Unknown Abnormal Normal Unknown

    Genital System: Abnormal Laboratory Results: Abnormal Normal Unknown Abnormal Normal Unknown

    Urinary System: Abnormal Normal Unknown

    Please list any genes for which you are requesting specific analysis or note any special requests here. (Please note: The lab will also generate a list of genes and variants based on clinical features and indication of study unless directed otherwise):

    ______________________________________________________________________________________________________________

    CLINICAL INFORMATION

    ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

    Patient name: ____________________________________________________ Date of birth: ________________ (MM/DD/YYYY) REQUISITION FORM

    ______________________________________________________________________________________________________________

    Page 2 of 3

  • BILLING INFORMATION AND AUTHORIZATION 1. BILL INSTITUTION Institution: Tax ID #: PO#: Claims Billing Address: City: State: Zip: Billing Contact Name: Phone: FAX:

    2. BILL INSURANCE Preauthorization is required for all insurance billing

    Do insurance preauthorization; PROCEED if approved (PREAUTH FORM and sample required) Do insurance preauthorization CONTACT PROVIDER if approved (PREAUTH FORM and sample required) Preauthorization already obtained; PreAuth approval number:

    Policyholder Name: Relationship to Patient: Self Parent Spouse Other (specify): Policyholder DOB: Dates of Coverage: Patient Policy ID#: Group Name: Group #: Insurance Company Name: Claims Billing Address: City: State: Zip: Phone: FAX: ICD10 Diagnosis Code(s): Patient Insurance Billing Consent: I authorize the NCGL to release to my designated insurance carrier, health plan, or third party administrator the information on this form and any other information provided by my health care provider necessary for reimbursement. I assign and authorize insurance payments to NCGL. I understand my insurance carrier may not approve and reimburse my medical genetic services in full due to usual and customary rate limits, benefit exclusions, coverage limits, lack of authorization, medical necessity, or otherwise. I understand I am responsible for fees not paid in full, co-payments, and policy deductibles except where my liability is limited by contract or State or Federal law. A duplicate or faxed copy of this authorization is considered the same as the original document.

    Patient Signature: Date:

    3. SELF-PAY Payment Method: Cashier Check/Money Order (Payable to UW Physicians)

    Credit Card: Please contact NCGL billing at (206) 221-1274 to provide credit card information over a secure line Electronic Funds Transfer (EFT) (See website for details) EFT Amount (USD):

    4. MEDICAID For Medicaid billing, the following is required: Medicaid claims address, Copy of Medicaid card (attach to requisition form), Letter of medical necessity from referring physician; impact on future care (attach to requisition form)

    5. MEDICARE For Medicare billing, a completed Advance Beneficiary Notice (ABN) is required (see website for form)

    SAMPLE & SHIPPING REQUIREMENTS Blood samples should be collected in lavender top (potassium EDTA) tubes: 7mL (3-5mL for infants). All samples must be labeled with two unique identifiers: 1) the patient's full name and 2) date of birth. If possible please include the patient's medical record number. Please contact the laboratory for more details and test kits (206-543-0459).

    Samples must be accompanied by a requisition form and signed consent forms (when applicable). Sample (with forms) should be shipped overnight at room temperature to:

    Laboratory for Precision Diagnostics Northwest Clinical Genomics Laboratory

    1959 NE Pacific St., HSC H-561 Seattle, WA 98195

    Page 3 of 3

  • Last revised: 11 June 2019

    UW Laboratory Center for Precision Diagnostics Northwest Clinical Genomics Laboratory Box 357655 1959 NE Pacific St., HSC H-561, Seattle, WA 98195

    Phone: 206-616-4115 206-221-9364 www.uwcpdx.org cpdx@uw.edu

    Patient Name: __________________________________________ Date of Birth: ___________________ (MM/DD/YYYY)

    CONSENT FOR CLINICAL EXOME OR GENOME (GENOMIC) SEQUENCING

    Test ordered: ______ Exome sequencing (sequencing of the coding portions of the genome) ______ Genome sequencing (sequencing of the coding and non-coding portions of the genome)

    Exome and genome sequencing tests are referred to as “genomic sequencing” throughout the following consent form. The technical limitations and caveats are applicable to both.

    Please read this form carefully. You are being offered a blood test that examines your genetic material. This testing may help us better understand your/your child's medical condition. This consent form will explain the testing, how results are released and potential risks and benefits of doing the test